GAP Exception Authorization Form

If you're a medical practice or doctor in need of a GAP Authorization processed fast and at a low price then all you need to do is fill this form out below and we will contact you within 24 hours to process.

⚠️ You do not need to be a client to use this service.
Please just fill out the form below:

  • Patient Information

  • MM slash DD slash YYYY
  • Max. file size: 1 GB.
  • Required Details

  • Facility Information (Hospital/Surgery Center)

  • Max. file size: 1 GB.